HomeMy WebLinkAboutBLDTR-23-00956 TOWN OF YARMOUTH /a67/63/ZZ
6Y`YARD
o BUILDING DEPARTIVIENT Permit Number
�g y 1146 Route 28,South Yarmouth, NIA 02664 --- =
or s'
S MAGI R'� 508-398-2231 ext. 1261 Fax 508- ' ._ . • Date Issued
RECEIVED
Expiation Date
AUG 19 2022
$50.00
BUI >NG DEPARTMENT
BY:__LRI _Psi �- IT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST RE FULLY COMPLETED PRIOR TO CONSIDERATION
Nacre of Applicant 6 C J p
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Street Addrewit `7 7 q-2-t
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City/Town MA ZIP
4-040u`f( 01 b11111111111111111111111111111111111111111111111
Name of Excavator(if different from applicant)
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Street Address
City Town ZIP
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Name of Owneris)of Property
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Street Address L l t1�57�1V
SitelARA IsJAY
Cky/ own MA ZIP
W Yi4 o itlitt b 2673
Other Contact
Description.location)andPermit Fee Received No Yes
Please describe the exact�Prrrt>�of proposed trench:
be laid in tko of the proposed trench sad its purpose(include a description of what is(or is intendedll to
Proposed trench(es;pipes/cable Hoes etc..)Please use reverse Nide if additional span is needed.
troT i c. I P S"ZAO-A-'T I0/J
insurance Certificate 0:
same sad Cavan information F -30
otrnation of Insurer;
k; its' Z6j21,-) --ric)t-, M :
Poi Er ration Date.
Dig Sate* Q 12. / _
.d Competent
.dame of Cum � b
Person(as defined by 520 t"NR 7.02):
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Massachusetts Hoisting License I -� C_. - / x'
•
License Grade: 4 E—c 4 Expiration Date: 1 1 ` 2 , c)•-
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
G.L c. S2A, 520 CMR 7.00 d sec„ AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMiIY WITH THE
CONDT IONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THIS PERMIT.INNPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR ARISING OUT
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLIC.N 'SI NAUJRE.
/1 -c /--I-"Al---- DATE " ifr - 2_2_
EXCAVA I SIGNATURE tIF DIFFERENT)
://, `..al----
DATE 12 - 2-2.-
OWNER'S SI fATU (IF DIFFERENT)
1%'�__ DATE: l
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